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Gao P, Zhang Y, Jin Y, Zhang P, Wang W, Liu J. Development and Validation of a Nomogram for Predicting Heparin Resistance in Neonates and Young Infants Undergoing Cardiac Surgery: A Retrospective Study. Anesth Analg 2024; 138:1233-1241. [PMID: 37216291 PMCID: PMC11081478 DOI: 10.1213/ane.0000000000006507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2023] [Indexed: 05/24/2023]
Abstract
BACKGROUND Heparin resistance (HR) is a common finding in pediatric cardiac surgery and generally refers to decreased sensitivity to heparin. Antithrombin (AT) deficiency is considered the primary mechanism of HR; however, the etiology of HR may be multifactorial. Early identification of HR might help optimize heparin anticoagulation management. This study aimed to develop a predictive nomogram for HR in neonates and young infants undergoing cardiac surgery. METHODS From January 2020 to August 2022, a total of 296 pediatric patients 1 to 180 days of age were included in this retrospective study. The patients were randomly divided into development and validation cohorts in a 7:3 ratio. Univariable logistic regression and the Least Absolute Shrinkage and Selection Operator (LASSO) regularization were used for variable selection. A multivariable logistic regression was performed to identify predictors and establish a nomogram to predict HR risk. Discrimination, calibration, and clinical usefulness were assessed in the development and validation cohorts. RESULTS After the multistep variable selection, AT activity, platelet count, and fibrinogen were predictors for HR in neonates and young infants. The prediction model constructed using these 3 factors achieved an area under the receiver operating characteristic curve (ROC-AUC) of 0.874 and 0.873 in the development and validation cohorts. The Hosmer-Lemeshow test did not find evidence of a lack of fit ( P = .768). The calibration curve of the nomogram was close to the ideal diagonal line. Furthermore, the model performed well in neonate and infant subgroups. CONCLUSIONS A nomogram based on preoperative variables was developed to predict the HR risk in neonates and young infants undergoing cardiac surgery. This provides clinicians with a simple tool for the early prediction of HR, which may help optimize heparin anticoagulation strategies in this vulnerable patient population.
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Affiliation(s)
- Peng Gao
- From the Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yang Zhang
- Department of Laboratory Medicine, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Jin
- Department of Cardiopulmonary Bypass, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Peiyao Zhang
- Department of Cardiopulmonary Bypass, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wenting Wang
- Department of Cardiopulmonary Bypass, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jinping Liu
- Department of Cardiopulmonary Bypass, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Levy JH, Sniecinski RM, Maier CL, Despotis GJ, Ghadimi K, Helms J, Ranucci M, Steiner ME, Tanaka KA, Connors JM. Finding a common definition of heparin resistance in adult cardiac surgery: communication from the ISTH SSC subcommittee on perioperative and critical care thrombosis and hemostasis. J Thromb Haemost 2024; 22:1249-1257. [PMID: 38215912 DOI: 10.1016/j.jtha.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 01/01/2024] [Accepted: 01/02/2024] [Indexed: 01/14/2024]
Abstract
Ensuring adequate anticoagulation for patients requiring cardiac surgery and cardiopulmonary bypass (CPB) is important due to the adverse consequences of inadequate anticoagulation with respect to bleeding and thrombosis. When target anticoagulation is not achieved with typical doses, the term heparin resistance is routinely used despite the lack of uniform diagnostic criteria. Prior reports and guidance documents that define heparin resistance in patients requiring CPB and guidance documents remain variable based on the lack of standardized criteria. As a result, we conducted a review of clinical trials and reports to evaluate the various heparin resistance definitions employed in this clinical setting and to identify potential standards for future clinical trials and clinical management. In addition, we also aimed to characterize the differences in the reported incidence of heparin resistance in the adult cardiac surgical literature based on the variability of both target-activated clotting (ACT) values and unfractionated heparin doses. Our findings suggest that the most extensively reported ACT target for CPB is 480 seconds or higher. Although most publications define heparin resistance as a failure to achieve this target after a weight-based dose of either 400 U/kg or 500 U/kg of heparin, a standardized definition would be useful to guide future clinical trials and help improve clinical management. We propose the inability to obtain an ACT target for CPB of 480 seconds or more after 500 U/kg as a standardized definition for heparin resistance in this setting.
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Affiliation(s)
- Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, North Carolina, USA.
| | - Roman M Sniecinski
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Cheryl L Maier
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - George J Despotis
- Departments of Pathology and Immunology, Division of Laboratory and Genomic Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Kamrouz Ghadimi
- Department of Anesthesiology, Divisions of Cardiothoracic Anesthesiology and Critical Care Medicine, Clinical Research Unit, Duke University School of Medicine, Durham, North Carolina, USA
| | - Julie Helms
- University Hospital, Medical Intensive Care Unit, Nouvel Hôpital Civil, Strasbourg, France; French National Institute of Health and Medical Research, Regenerative Nanomedicine, Strasbourg, France
| | - Marco Ranucci
- Department of Cardiothoracic, Anesthesia and Intensive Care, Policlinico San Donato, Milan, Italy
| | - Marie E Steiner
- Department of Pediatrics, Divisions of Hematology/Oncology and Critical Care, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kenichi A Tanaka
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Jean M Connors
- Hematology Division Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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3
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Cross B, Turner RM, Zhang JE, Pirmohamed M. Being precise with anticoagulation to reduce adverse drug reactions: are we there yet? THE PHARMACOGENOMICS JOURNAL 2024; 24:7. [PMID: 38443337 PMCID: PMC10914631 DOI: 10.1038/s41397-024-00329-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 02/11/2024] [Accepted: 02/15/2024] [Indexed: 03/07/2024]
Abstract
Anticoagulants are potent therapeutics widely used in medical and surgical settings, and the amount spent on anticoagulation is rising. Although warfarin remains a widely prescribed oral anticoagulant, prescriptions of direct oral anticoagulants (DOACs) have increased rapidly. Heparin-based parenteral anticoagulants include both unfractionated and low molecular weight heparins (LMWHs). In clinical practice, anticoagulants are generally well tolerated, although interindividual variability in response is apparent. This variability in anticoagulant response can lead to serious incident thrombosis, haemorrhage and off-target adverse reactions such as heparin-induced thrombocytopaenia (HIT). This review seeks to highlight the genetic, environmental and clinical factors associated with variability in anticoagulant response, and review the current evidence base for tailoring the drug, dose, and/or monitoring decisions to identified patient subgroups to improve anticoagulant safety. Areas that would benefit from further research are also identified. Validated variants in VKORC1, CYP2C9 and CYP4F2 constitute biomarkers for differential warfarin response and genotype-informed warfarin dosing has been shown to reduce adverse clinical events. Polymorphisms in CES1 appear relevant to dabigatran exposure but the genetic studies focusing on clinical outcomes such as bleeding are sparse. The influence of body weight on LMWH response merits further attention, as does the relationship between anti-Xa levels and clinical outcomes. Ultimately, safe and effective anticoagulation requires both a deeper parsing of factors contributing to variable response, and further prospective studies to determine optimal therapeutic strategies in identified higher risk subgroups.
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Affiliation(s)
- Benjamin Cross
- Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology, The University of Liverpool, 1-5 Brownlow Street, Liverpool, L69 3GL, UK
| | - Richard M Turner
- Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology, The University of Liverpool, 1-5 Brownlow Street, Liverpool, L69 3GL, UK
- GSK, Stevenage, Hertfordshire, SG1 2NY, UK
| | - J Eunice Zhang
- Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology, The University of Liverpool, 1-5 Brownlow Street, Liverpool, L69 3GL, UK
| | - Munir Pirmohamed
- Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology, The University of Liverpool, 1-5 Brownlow Street, Liverpool, L69 3GL, UK.
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4
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Yamashiro T, Takami Y, Takagi Y. Contributing factors to heparin resistance during cardiopulmonary bypass. J Artif Organs 2024:10.1007/s10047-024-01435-1. [PMID: 38367099 DOI: 10.1007/s10047-024-01435-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 01/18/2024] [Indexed: 02/19/2024]
Abstract
Since the risk factors for heparin resistance (HR) before cardiopulmonary bypass (CPB) have not been fully clarified, this study investigated the contributing factors for HR after the initial unfractionated heparin (UFH) dose of 500 IU/kg. We retrospectively analyzed the data of 371 patients who underwent CPB surgery, with the initial UFH dose of 500 IU/kg, between May 2017 and December 2021. We defined HR as the failure to achieve activated clotting time (ACT) of > 480 s after the initial UFH dose of 500 IU/kg. HR was observed in 36 patients (9.7%) (HR group), while HR was not observed in 335 patients (control group). The HR group included significantly more patients with preoperative use of UFH, with significantly higher white blood cell counts, fibrinogen, fibrinogen degradation products, D-dimer, and C-reactive protein, and lower hemoglobin and albumin. The multivariable logistic regression analysis identified albumin (OR: 3.09, 95% CI 1.3504-7.0845, p = 0.0075) and fibrinogen (OR: 0.99, 95% CI 0.9869-0.9963, p = 0.0003) as independent predictors for HR. Using the Youden index, the cutoffs of albumin and fibrinogen were calculated as 3.8 g/dL and 303 mg/dL, respectively. The receiver operating characteristic curves showed the predictive performance of albumin (area under the curve (AUC): 0.78, sensitivity: 65%, specificity: 81%) and fibrinogen (AUC: 0.77, sensitivity: 56%, specificity: 88%). The incidence of HR after the initial UFH dose of 500 IU/kg was 9.7%. The preoperative albumin < 3.8 g/dL and fibrinogen > 303 mg/dL were independent predictors for HR.
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Affiliation(s)
- Tomoaki Yamashiro
- Department of Clinical Engineering, Fujita Health University Hospital, 1-98 Dengakugakubo, Kutsukake, Toyoake, Aichi, 470-1192, Japan.
| | - Yoshiyuki Takami
- Department of Cardiovascular Surgery, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake, Toyoake, Aichi, 470-1192, Japan.
| | - Yasushi Takagi
- Department of Cardiovascular Surgery, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake, Toyoake, Aichi, 470-1192, Japan
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5
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Ito K, Sasaki K, Ono M, Suzuki T, Sakamoto K, Okamoto H, Katori N, Momose N, Araki Y, Tojo K, Ieko M, Komiyama Y, Saiki Y. Investigation of real-world heparin resistance and anticoagulation management prior to cardiopulmonary bypass: report from a nationwide survey by the Japanese Association for Thoracic Surgery heparin resistance working group. Gen Thorac Cardiovasc Surg 2024; 72:8-14. [PMID: 37195584 PMCID: PMC10766675 DOI: 10.1007/s11748-023-01936-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 04/14/2023] [Indexed: 05/18/2023]
Abstract
OBJECTIVE Heparin resistance is often encountered during cardiopulmonary bypass. Heparin dose and activated clotting time target values for the initiation of cardiopulmonary bypass are not yet universally standardized; further no consensus exists on the management of heparin resistance. This study aimed to investigate the current real-world practice on heparin management and anticoagulant treatment for heparin resistance in Japan. METHODS A questionnaire survey was conducted at medical institutions nationwide with which The Japanese Society of Extra-Corporeal Technology in Medicine members are affiliated, targeting surgical cases with cardiopulmonary bypass performed from January 2019 through December 2019. RESULTS Among 69% (230/332) of the participating institutions, the criterion for heparin resistance was defined as "the target activated clotting time value not reached even with an additional dose of heparin administration". Cases of heparin resistance were reported in 89.8% (202/225) of the responded institutions. Of note, 75% (106/141) of the responded institutions reported heparin resistance associated with antithrombin activity ≥ 80%. Antithrombin concentrate was used in 38.4% (238/619 responses) or third dose of heparin in 37.8% (234/619 responses) for advanced heparin resistance treatment. Antithrombin concentrate was found to be effective in resolving heparin resistance in patients having normal, as well as lower antithrombin activity. CONCLUSION Heparin resistance has occurred in many cardiovascular centers, even among patients with normal antithrombin activities. Interestingly, the administration of antithrombin concentrate resolved heparin resistance, regardless of the baseline antithrombin activity value.
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Affiliation(s)
- Koki Ito
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryomachi, Aoba-ku, Sendai, 980-8574, Japan
| | - Konosuke Sasaki
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryomachi, Aoba-ku, Sendai, 980-8574, Japan
| | - Minoru Ono
- Department of Cardiac Surgery, The University of Tokyo, Tokyo, Japan
| | - Takaaki Suzuki
- Department of Pediatric Cardiac Surgery, Saitama Medical University International Medical Center, Saitama, Japan
| | - Kisaburo Sakamoto
- Department of Cardiovascular Surgery, Mt. Fuji Shizuoka Children's Hospital, Shizuoka, Japan
| | - Hirotsugu Okamoto
- Department of Anesthesiology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Nobuyuki Katori
- Department of Anesthesiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Naoki Momose
- Department of Medical Center, Jichi Medical University, Saitama, Japan
| | - Yasuyuki Araki
- Department of Clinical Engineering, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Keiichi Tojo
- Department of Medical Engineering, Kitasato University Hospital, Sagamihara, Japan
| | - Masahiro Ieko
- Department of Hematology, Iwate Prefectural Chubu Hospital, Kitakami, Japan
| | - Yutaka Komiyama
- Faculty of Health and Medical Sciences, Hokuriku University, Kanazawa, Japan
| | - Yoshikatsu Saiki
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryomachi, Aoba-ku, Sendai, 980-8574, Japan.
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Shibahashi E, Abe T, Kamishima K, Ebihara S, Moriyama T, Shimazaki K, Saito K, Uchigata Y, Jujo K. Direct Oral Anticoagulants Affect Activated Clotting Time During and Bleeding Events After Percutaneous Coronary Intervention. Am J Cardiol 2023; 204:1-8. [PMID: 37531715 DOI: 10.1016/j.amjcard.2023.07.092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 06/18/2023] [Accepted: 07/14/2023] [Indexed: 08/04/2023]
Abstract
Inappropriately high activated clotting time (ACT) during percutaneous coronary intervention (PCI) is associated with an increased risk of bleeding events. However, whether the prescription of direct oral anticoagulants (DOACs) affects ACT kinetics during heparin use and adverse clinical events in patients who underwent PCI remains unclear. We aimed to evaluate the relations between ACT changes during and adverse clinical events after PCI in patients who were prescribed DOAC. This observational study included 246 patients who underwent PCI at the 2 cardiovascular centers who were not receiving warfarin and whose ACT was recorded immediately before and 30 minutes after injection of unfractionated heparin. Patients were divided into 2 groups according to DOAC prescription at the time of the index PCI: DOAC users (n = 31) and nonusers (n = 215). Any bleeding and systemic thromboembolic events were investigated until 30 days after PCI. The average age of this population was 70.5 years, and 66.3% were male. Average ACT was significantly higher in DOAC users than nonusers both before and 30 minutes after unfractionated heparin induction (157.2 ± 30.1 vs 131.8 ± 25.1 seconds, p <0.001; 371.1 ± 122.2 vs 308.3 ± 82.2 seconds, p <0.001; respectively). The incidence of systemic thromboembolism after PCI was low and comparable between the 2 groups (0% vs 3.7%, p = 0.60). However, the rate of any bleeding event was significantly higher in DOAC users than in nonusers (16.1% vs 4.7%, p = 0.028). Patients receiving DOAC have higher ACT during PCI and higher incidence of bleeding events than those not receiving DOAC.
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Affiliation(s)
- Eiji Shibahashi
- Department of Cardiovascular Intervention, Tokyo Women's Medical University Adachi Medical Center, Tokyo, Japan
| | - Takuro Abe
- Department of Cardiology, Nishiarai Heart Center Hospital, Tokyo, Japan
| | | | | | - Tetsu Moriyama
- Department of Cardiology, Nishiarai Heart Center Hospital, Tokyo, Japan
| | - Kensuke Shimazaki
- Department of Cardiology, Nishiarai Heart Center Hospital, Tokyo, Japan
| | - Katsumi Saito
- Department of Cardiology, Nishiarai Heart Center Hospital, Tokyo, Japan
| | - Yasuko Uchigata
- Department of Cardiovascular Intervention, Tokyo Women's Medical University Adachi Medical Center, Tokyo, Japan
| | - Kentaro Jujo
- Department of Cardiovascular Intervention, Tokyo Women's Medical University Adachi Medical Center, Tokyo, Japan; Department of Cardiology, Nishiarai Heart Center Hospital, Tokyo, Japan.
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7
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Ranucci M, Baryshnikova E, Pistuddi V, Di Dedda U. The Rise and Fall of Antithrombin Supplementation in Cardiac Surgery. Anesth Analg 2022; 136:1043-1051. [PMID: 36853953 DOI: 10.1213/ane.0000000000006314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
Various cohort studies, both retrospective and prospective, showed that low antithrombin levels after cardiac surgery (at the arrival in the intensive care unit and during the next days) were associated with a number of adverse outcomes, including surgical reexploration and thromboembolic events, eventually leading to prolonged stay in the intensive care. Values lower than 58% to 64% of antithrombin activity were indicative of this higher morbidity with good sensitivity and specificity. The scenario generated the hypothesis that low antithrombin levels needed to be corrected by supplementation to improve postoperative outcome. However, randomized controlled studies run to test this idea failed to demonstrate any benefit of antithrombin supplementation, showing no effects on outcome, neither as preemptive preoperative strategy nor for treating postoperative low antithrombin values. In addition, randomized trials highlighted that those patients who received antithrombin experienced significantly higher incidence of acute kidney injury with a pooled odds ratio of 4.41 (95% CI, 1.90-10.23; P = .001). A strongly decreased thrombin activity after antithrombin correction may eventually affect the efficiency of the glomerular filtration and cause the deterioration of kidney function, but underlying biological mechanisms remain unclear. In conclusion, low levels of antithrombin activity after cardiac surgery should be considered as a marker of greater severity of the patient's conditions and/or of the complexity of the surgical procedure. There are no indications for antithrombin supplementation in cardiac surgery unless for correcting heparin resistance.
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Affiliation(s)
- Marco Ranucci
- From the Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, Milan, Italy
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8
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Fetters L, Sirianni S. Off Target: Case Report of Heparin Resistance in a Neurosurgical Intensive Care Unit Patient. Crit Care Nurse 2021; 41:33-41. [PMID: 34061194 DOI: 10.4037/ccn2021303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Heparin resistance was discovered in a patient in the surgical intensive care unit who underwent emergency endovascular coiling and later an anterior communicating artery clipping procedure to treat subarachnoid hemorrhage due to rupture of an anterior communicating artery aneurysm. CLINICAL FINDINGS On intensive care unit day 17/postoperative day 3, the patient experienced shortness of breath, persistent tachycardia, and hypoxia. Bilateral pulmonary emboli, a saddle embolus, and lower-extremity and upper-extremity deep vein thrombi were diagnosed. The patient received high-dose unfractionated heparin (>35 000 U/24 h), and activated partial thromboplastin times remained subtherapeutic over the next 72 hours. DIAGNOSIS Factor VIII activity, fibrinogen, antithrombin activity, antithrombin antigen, and platelet factor 4 were measured. The results demonstrated an increase in factor VIII activity to 342% (reference range, 50%-200%), elevated fibrinogen level of 441 mg/dL (reference range, 200-400 mg/dL), antithrombin antigen level of 92% (reference range, 80%-130%), elevated antithrombin activity of 108% (reference range, 80%-100%), and negative platelet factor 4 result, indicating that the patient did not have heparin-induced thrombocytopenia and confirming the diagnosis of heparin resistance. CONCLUSIONS Risk factors for heparin resistance include antithrombin deficiency, elevation of factor VIII or fibrinogen level, elevation in heparin-binding proteins, increased heparin clearance, sepsis, trauma, and burns. The astute critical care nurse may be the first to recognize this condition in a patient, preventing a potentially fatal complication.
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Affiliation(s)
- Lisa Fetters
- Lisa Fetters is an acute care nurse practitioner, a certified acute care clinical nurse specialist, and an assistant professor at the University of Michigan-Flint School of Nursing, Flint, Michigan
| | - Sue Sirianni
- Sue Sirianni is the lead nurse practitioner in the surgical intensive care unit at Sinai-Grace Hospital, Detroit, Michigan, and an adjunct associate professor at Madonna University, Livonia, Michigan
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9
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Kimura Y, Okahara S, Abo K, Koyama Y, Kuriyama M, Ono K, Hidaka H. Infective Endocarditis Is a Risk Factor for Heparin Resistance in Adult Cardiovascular Surgical Procedures: A Retrospective Study. J Cardiothorac Vasc Anesth 2021; 35:3568-3573. [PMID: 34144872 DOI: 10.1053/j.jvca.2021.05.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 05/09/2021] [Accepted: 05/10/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Heparin resistance (HR), defined as a decrease in heparin responsiveness, can result in adverse events with prolonged duration of surgery. Although some clinical risk factors have been suggested, the relationship with the surgical diagnosis is unclear. The aim of present study was to elucidate the clinical predictors of HR including the surgical diagnosis. DESIGN This retrospective cohort study determined the incidence of HR (defined as activated clotting time [ACT] <400 seconds after 250-350 IU/kg of heparin administration) and heparin sensitivity index (HSI) was calculated from the rate of change in ACT per heparin dose. Preoperative demographic data, medication history, and laboratory data also were analyzed. SETTING Single institution, tertiary care hospital. PARTICIPANTS Adult patients who underwent cardiovascular surgery with cardiopulmonary bypass between January 2012 and September 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 287 patients, 88 (30.7%) were classified as HR. In univariate analysis, infective endocarditis (IE), platelet count, and serum fibrinogen and albumin levels were associated with HR. After adjustment for baseline ACT and initial heparin dose, IE (odds ratio 4.57, [95% CI: 1.10-19.1]; p = 0.037) and albumin ≤3.5 g/dL (3.17, [1.46-6.93]; p = 0.004) were associated independently with HR. Patients with IE had significantly lower HSI than those with other diseases. All HR patients were treated with additional heparin, and 17 of them received human antithrombin-III concentrate. CONCLUSIONS Infective endocarditis and preoperative hypoalbuminemia were associated independently with HR. The optimal anticoagulation strategy for patients with these risk factors requires further investigations based on the authors' findings.
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Affiliation(s)
- Yoshikazu Kimura
- Department of Anesthesiology and Oncological Pain Medicine, Fukuyama City Hospital, Hiroshima, Japan.
| | - Shuji Okahara
- Department of Intensive Care Medicine, Okayama University Hospital, Okayama, Japan
| | - Kanae Abo
- Department of Anesthesiology and Oncological Pain Medicine, Fukuyama City Hospital, Hiroshima, Japan
| | - Yusuke Koyama
- Department of Anesthesiology and Oncological Pain Medicine, Fukuyama City Hospital, Hiroshima, Japan
| | - Mitsuhito Kuriyama
- Department of Cardiovascular Surgery, Saiseikai Imabari Hospital, Ehime, Japan
| | - Kazumi Ono
- Department of Anesthesiology and Intensive Care Medicine, Kawasaki Medical School, Okayama, Japan
| | - Hidekuni Hidaka
- Department of Anesthesiology and Oncological Pain Medicine, Fukuyama City Hospital, Hiroshima, Japan
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10
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A Randomized Controlled Trial of Antithrombin Supplementation During Extracorporeal Membrane Oxygenation. Crit Care Med 2020; 48:1636-1644. [DOI: 10.1097/ccm.0000000000004590] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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11
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Houston E, Moran P, Mayhew D. Massive atrial myxoma requiring emergency cardiopulmonary bypass in a patient with heparin resistance. Anaesth Rep 2020; 8:103-106. [PMID: 32789291 DOI: 10.1002/anr3.12063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2020] [Indexed: 11/06/2022] Open
Abstract
Heparin exhibits complex pharmacology with a wide variation in individual response. Despite this, heparin is the most commonly used anticoagulant during cardiopulmonary bypass. Heparin resistance in the context of a patient with severe cardiovascular compromise presents a potentially life-threatening challenge. A 31-year-old woman was listed for emergency excision of a massive left atrial myxoma. On induction of anaesthesia, she developed marked cardiovascular instability secondary to mitral inflow obstruction. An initial heparin dose of 600 units.kg-1 produced an activated clotting time of 360 s; however, immediate cardiopulmonary bypass was required. Heparin resistance remained problematic throughout the procedure, with an inadequate response to antithrombin three supplementation. Despite a total dose of 120,000 units of heparin, anticoagulation was fully reversed with 500 mg protamine and there was no subsequent re-heparinisation. Heparin resistance, when coinciding with profound cardiovascular instability, requires a pragmatic response to expedite establishment of cardiopulmonary bypass whilst minimising potential harm. In this case, successful cardiopulmonary bypass was achieved with additional heparin boluses from an alternative batch administered both intravenously and via the bypass circuit. We therefore advocate consideration of this approach as one possible solution to achieving safe entry onto cardiopulmonary bypass in a crisis scenario.
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Affiliation(s)
- E Houston
- North West (Mersey) Deanery Liverpool UK
| | - P Moran
- North West (Mersey) Deanery Liverpool UK
| | - D Mayhew
- Cardiothoracic Anaesthesia and Intensive Care Medicine Liverpool Heart and Chest Hospital Liverpool UK.,University of Liverpool UK
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12
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Neethling E, Moreno Garijo J, Mangalam TK, Badiwala MV, Billia P, Wasowicz M, Van Rensburg A, Slinger P. Intraoperative and Early Postoperative Management of Heart Transplantation: Anesthetic Implications. J Cardiothorac Vasc Anesth 2020; 34:2189-2206. [DOI: 10.1053/j.jvca.2019.09.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 09/07/2019] [Accepted: 09/24/2019] [Indexed: 12/16/2022]
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13
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Matsushita S, Kishida A, Wakamatsu Y, Mukaida H, Yokokawa H, Yamamoto T, Amano A. Factors influencing activated clotting time following heparin administration for the initiation of cardiopulmonary bypass. Gen Thorac Cardiovasc Surg 2020; 69:38-43. [PMID: 32656705 DOI: 10.1007/s11748-020-01435-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Accepted: 07/05/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Initiation of cardiopulmonary bypass (CPB) for open-heart surgery requires that heparin be administered and reach an adequate value of activated clotting time (ACT). We previously introduced a new heparin formula that considered the preoperative ACT. In this study, we determined other factors affecting ACT. METHODS Adult patients who underwent cardiac surgery using CPB were divided into two groups according to their ACT value after the initial administration of heparin during surgery. ACT above 450 s was defined as "Reach", and this group was compared to the "Short" group with ACT below 450 s. RESULTS The Reach and Short groups included 334 (64.7%) and 182 (35.3%) cases, respectively. Univariate analysis indicated that preoperative heparin use, age ≥ 80 years, New York Heart Association classification 4, white blood cell counts above the higher limit, hematocrit below the lower limit, platelet cell counts below the lower limit, low albumin levels, moderate renal dysfunction, high C-reactive protein levels, high brain natriuretic peptide levels, and moderate deterioration of left ventricular ejection fraction were associated with the effects of heparin. Multivariate analysis revealed that age ≥ 80 years (odds ratio [OR] 2.53, 95% confidence interval [95%CI] 1.41-5.24), New York Heart Association classification 4 (OR = 4.44, 95%CI 1.59-15.35), and platelet count below the lower limit (OR 0.37, 95%CI 0.31-0.85) were associated with the effects of heparin. CONCLUSION Old age, heart failure, and lower platelet counts affected heparin activity. The dose of heparin should be considered in those patients to reach the target ACT.
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Affiliation(s)
- Satoshi Matsushita
- Faculty of Medicine, Department of Cardiovascular Surgery, Juntendo University, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.
| | - Akinori Kishida
- Department of Medical Engineer, Juntendo Hospital, Tokyo, Japan
| | | | - Hiroshi Mukaida
- Department of Medical Engineer, Juntendo Hospital, Tokyo, Japan
| | - Hirohide Yokokawa
- Faculty of Medicine, Department of General Medicine, Juntendo University, Tokyo, Japan
| | - Taira Yamamoto
- Faculty of Medicine, Department of Cardiovascular Surgery, Juntendo University, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Atsushi Amano
- Faculty of Medicine, Department of Cardiovascular Surgery, Juntendo University, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
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14
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Bachler M, Hell T, Bösch J, Treml B, Schenk B, Treichl B, Friesenecker B, Lorenz I, Stengg D, Hruby S, Wallner B, Oswald E, Ströhle M, Niederwanger C, Irsara C, Fries D. A Prospective Pilot Trial to Assess the Efficacy of Argatroban (Argatra ®) in Critically Ill Patients with Heparin Resistance. J Clin Med 2020; 9:jcm9040963. [PMID: 32244368 PMCID: PMC7230377 DOI: 10.3390/jcm9040963] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 03/21/2020] [Accepted: 03/27/2020] [Indexed: 12/02/2022] Open
Abstract
The current study aims to evaluate whether prophylactic anticoagulation using argatroban or an increased dose of unfractionated heparin (UFH) is effective in achieving the targeted activated partial thromboplastin time (aPTT) of more than 45 s in critically ill heparin-resistant (HR) patients. Patients were randomized either to continue receiving an increased dose of UFH, or to be treated with argatroban. The endpoints were defined as achieving an aPTT target of more than 45 s at 7 h and 24 h. This clinical trial was registered on clinicaltrials.gov (NCT01734252) and on EudraCT (2012-000487-23). A total of 42 patients, 20 patients in the heparin and 22 in the argatroban group, were included. Of the patients with continued heparin treatment 55% achieved the target aPTT at 7 h, while only 40% of this group maintained the target aPTT after 24 h. Of the argatroban group 59% reached the target aPTT at 7 h, while at 24 h 86% of these patients maintained the targeted aPTT. Treatment success at 7 h did not differ between the groups (p = 0.1000), whereas at 24 h argatroban showed significantly greater efficacy (p = 0.0021) than did heparin. Argatroban also worked better in maintaining adequate anticoagulation in the further course of the study. There was no significant difference in the occurrence of bleeding or thromboembolic complications between the treatment groups. In the case of heparin-resistant critically ill patients, argatroban showed greater efficacy than did an increased dose of heparin in achieving adequate anticoagulation at 24 h and in maintaining the targeted aPTT goal throughout the treatment phase.
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Affiliation(s)
- Mirjam Bachler
- Institute for Sports Medicine, Alpine Medicine and Health Tourism, UMIT - University for Health Sciences, Medical Informatics and Technology, 6060 Hall in Tirol, Austria;
| | - Tobias Hell
- Department of Mathematics, Faculty of Mathematics, Computer Science and Physics, University of Innsbruck, 6020 Innsbruck, Austria;
| | - Johannes Bösch
- Department of General and Surgical Critical Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (J.B.); (B.S.); (B.F.); (I.L.); (D.S.); (S.H.); (B.W.); (M.S.); (D.F.)
| | - Benedikt Treml
- Department of General and Surgical Critical Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (J.B.); (B.S.); (B.F.); (I.L.); (D.S.); (S.H.); (B.W.); (M.S.); (D.F.)
- Correspondence: ; Tel.: +43-050-504-822-31
| | - Bettina Schenk
- Department of General and Surgical Critical Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (J.B.); (B.S.); (B.F.); (I.L.); (D.S.); (S.H.); (B.W.); (M.S.); (D.F.)
| | - Benjamin Treichl
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (B.T.); (E.O.)
| | - Barbara Friesenecker
- Department of General and Surgical Critical Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (J.B.); (B.S.); (B.F.); (I.L.); (D.S.); (S.H.); (B.W.); (M.S.); (D.F.)
| | - Ingo Lorenz
- Department of General and Surgical Critical Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (J.B.); (B.S.); (B.F.); (I.L.); (D.S.); (S.H.); (B.W.); (M.S.); (D.F.)
| | - Daniel Stengg
- Department of General and Surgical Critical Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (J.B.); (B.S.); (B.F.); (I.L.); (D.S.); (S.H.); (B.W.); (M.S.); (D.F.)
| | - Stefan Hruby
- Department of General and Surgical Critical Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (J.B.); (B.S.); (B.F.); (I.L.); (D.S.); (S.H.); (B.W.); (M.S.); (D.F.)
| | - Bernd Wallner
- Department of General and Surgical Critical Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (J.B.); (B.S.); (B.F.); (I.L.); (D.S.); (S.H.); (B.W.); (M.S.); (D.F.)
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (B.T.); (E.O.)
| | - Elgar Oswald
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (B.T.); (E.O.)
| | - Mathias Ströhle
- Department of General and Surgical Critical Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (J.B.); (B.S.); (B.F.); (I.L.); (D.S.); (S.H.); (B.W.); (M.S.); (D.F.)
| | - Christian Niederwanger
- Department of Pediatrics, Pediatrics I, Intensive Care Unit, Medical University of Innsbruck, 6020 Innsbruck, Austria;
| | - Christian Irsara
- Central Institute for Medical and Chemical Laboratory Diagnostics, Medical University of Innsbruck, 6020 Innsbruck, Austria;
| | - Dietmar Fries
- Department of General and Surgical Critical Care Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (J.B.); (B.S.); (B.F.); (I.L.); (D.S.); (S.H.); (B.W.); (M.S.); (D.F.)
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15
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Smith BB, Boswell MR, Matzek LJ, Smith MM. Thrombocytosis: Perioperative Considerations for Patients Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 34:772-781. [DOI: 10.1053/j.jvca.2019.07.131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 06/21/2019] [Accepted: 07/11/2019] [Indexed: 11/11/2022]
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16
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Abstract
It is well known that antithrombin (AT) deficiency results in decreased heparin sensitivity, also known as "heparin resistance." However, non-AT-mediated causes of heparin resistance are generally poorly characterized and less prevalent in the literature. We present 2 case reports of non-AT-mediated heparin resistance during cardiac surgery due to paraproteinemia and hyperfibrinogenemia. These cases highlight the challenges posed by unusual conditions in achieving adequate anticoagulation for cardiopulmonary bypass (CPB). The pros and cons of the treatment selections for these cases are discussed, and the potential complications of large doses of unfractionated heparin are considered.
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17
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Muedra V, Moreno L, Rodilla V, Arce C, Montó F, Blázquez Á, Pérez P, D’Ocón P. Dexamethasone Preconditioning in Cardiac Procedures Reduces Decreased Antithrombin Activity and Is Associated to Beneficial Outcomes: Role of Endothelium. Front Pharmacol 2018; 9:1014. [PMID: 30319401 PMCID: PMC6167415 DOI: 10.3389/fphar.2018.01014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Accepted: 08/20/2018] [Indexed: 01/07/2023] Open
Abstract
Introduction: Decreased antithrombin (AT) activity in patients scheduled for cardiovascular surgery under cardiopulmonary bypass (CPB) is related to increased postoperative complications and hospitalization time. Indirect evidence suggests that glucocorticoids mitigate this decreased AT activity. To better understand the beneficial effects of AT we have analyzed: (i) the clinical relevance of acute dexamethasone (DX) administration before cardiac surgery on AT activity, (ii) the modulation by DX of AT expression in human endothelial cells (hECs), (iii) the activity of AT on migration and angiogenesis of hECs, or on angiogenesis of rat aorta. Methods: A retrospective cohort study in patients undergoing aortic valve replacement surgery was designed to evaluate the effect of DX administration on AT activity at five separate time points: preoperatively, during CPB, at intensive care unit admission and at 12 and 24 h post-intervention. We have analyzed also clinical differences in postoperative outcomes as safety and the length of stay in hospitalization. Changes in mRNA levels of AT induced by DX were determined by qRT-PCR in human coronary (hCEC), aorta (hAEC) and cardiac microvasculature (hCMEC) endothelial cells. AT activity on migration and angiogenesis were also assayed. Angiogenic growth of rat aortic rings incubated in Matrigel® was determined in presence and absence of AT. Results: The cohort comprised 51 patients in the control group and 29 patients in the group receiving dexamethasone. Preoperative DX supplementation reduced intraoperative decrease of AT activity (67.71 ± 10.49% DX treated vs. 58.12 ± 9.11% untreated, p < 0.001) that could be related to a decrease in the hospitalization time (7.59 ± 4.08 days DX treated vs. 13.59 ± 16.00 days untreated, p = 0.014). Treatment of hECs with 500 nM DX slightly increased AT expression. Incubation with 0.5 and 1 IU/mL of AT increased migration and angiogenesis in hCAECs and hAECs, but not in hCMECs. The same concentrations of AT potentiated angiogenic sprouting of new vessels from rat aorta. Conclusion: Preoperative DX supplementation could be an interesting procedure to avoid excessive decrease in AT levels during cardiac surgery. Positive outcomes associated with maintaining adequate AT levels could be related to its potential beneficial effect on endothelial function (migration and angiogenesis).
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Affiliation(s)
- Vicente Muedra
- Departamento de Anestesiología, Cuidados Críticos y Terapéutica del Dolor, Hospital Universitario de La Ribera, Valencia, Spain
- Departamento de Cirugía, Facultad de Ciencias de la Salud, Universidad CEU Cardenal Herrera, Valencia, Spain
| | - Lucrecia Moreno
- Departamento de Farmacia, Facultad de Ciencias de la Salud, Universidad CEU Cardenal Herrera, Valencia, Spain
| | - Vicente Rodilla
- Departamento de Farmacia, Facultad de Ciencias de la Salud, Universidad CEU Cardenal Herrera, Valencia, Spain
| | - Cristina Arce
- Departamento de Farmacología, Facultad de Farmacia, Universitat de València, Valencia, Spain
- Estructura de Recerca Interdisciplinar en Biotecnologia i Biomedicina (ERI BIOTECMED), Universitat de València, Valencia, Spain
| | - Fermi Montó
- Departamento de Farmacología, Facultad de Farmacia, Universitat de València, Valencia, Spain
- Estructura de Recerca Interdisciplinar en Biotecnologia i Biomedicina (ERI BIOTECMED), Universitat de València, Valencia, Spain
| | - Águeda Blázquez
- Departamento de Farmacología, Facultad de Farmacia, Universitat de València, Valencia, Spain
| | - Paloma Pérez
- Instituto de Biomedicina de Valencia-Consejo Superior de Investigaciones Científicas (IBV-CSIC), Valencia, Spain
| | - Pilar D’Ocón
- Departamento de Farmacología, Facultad de Farmacia, Universitat de València, Valencia, Spain
- Estructura de Recerca Interdisciplinar en Biotecnologia i Biomedicina (ERI BIOTECMED), Universitat de València, Valencia, Spain
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18
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Balandina AN, Serebriyskiy II, Poletaev AV, Polokhov DM, Gracheva MA, Koltsova EM, Vardanyan DM, Taranenko IA, Krylov AY, Urnova ES, Lobastov KV, Chernyakov AV, Shulutko EM, Momot AP, Shulutko AM, Ataullakhanov FI. Thrombodynamics-A new global hemostasis assay for heparin monitoring in patients under the anticoagulant treatment. PLoS One 2018; 13:e0199900. [PMID: 29953528 PMCID: PMC6023127 DOI: 10.1371/journal.pone.0199900] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 06/17/2018] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Heparin therapy and prophylaxis may be accompanied by bleeding and thrombotic complications due to individual responses to treatment. Dosage control based on standard laboratory assays poorly reflects the effect of the therapy. The aim of our work was to compare the heparin sensitivity of new thrombodynamics (TD) assay with sensitivity of other standard and global coagulation tests available to date. STUDY POPULATION AND METHODS A total of 296 patients with high risk of venous thromboembolism (deep vein thrombosis (DVT), early postoperative period, hemoblastosis) were enrolled in the study. We used a case-crossover design to evaluate the sensitivity of new thrombodynamics assay (TD) to the hemostatic state before and after unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH) therapy/prophylaxis and to compare it with the activated partial thromboplastin time (APTT), anti-Xa activity test, thrombin generation test (TGT) and thromboelastography (TEG). A receiver operating characteristic (ROC) curve analysis was used to evaluate changes before and after heparin prophylaxis and therapy. Blood was sampled before heparin injection, at the time of maximal blood heparin concentration and before the next injection. RESULTS Hypercoagulation before the start of heparin treatment was detected by TD, TGT and TEG but not by APTT. The area under the ROC curve (AUC) was maximal for TD and anti-Xa, intermediate for TGT and TEG and minimal for APTT. CONCLUSIONS These results indicate that TD has a high sensitivity to the effects of UFH and LMWH after both prophylactic and therapeutic regimes and may be used for heparin monitoring.
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Affiliation(s)
- Anna N. Balandina
- Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
- Center for Theoretical Problems of Physicochemical Pharmacology, Moscow, Russia
| | | | - Alexander V. Poletaev
- Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Dmitry M. Polokhov
- Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Marina A. Gracheva
- Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Ekaterina M. Koltsova
- Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
- Center for Theoretical Problems of Physicochemical Pharmacology, Moscow, Russia
| | | | | | - Alexey Yu. Krylov
- Federal State Autonomous Educational Institution of Higher Education I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | | | | | | | | | - Andrey P. Momot
- National Research Center for Hematology, Altay Department, Barnaul, Russia
| | - Alexander M. Shulutko
- Federal State Autonomous Educational Institution of Higher Education I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Fazoil I. Ataullakhanov
- Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
- Center for Theoretical Problems of Physicochemical Pharmacology, Moscow, Russia
- Moscow State University, Moscow, Russia
- Moscow Institute of Physics and Technology, Dolgoprudny, Russia
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19
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Kawatsu S, Sasaki K, Sakatsume K, Takahara S, Hosoyama K, Masaki N, Suzuki Y, Hayatsu Y, Yoshioka I, Sakuma K, Adachi O, Akiyama M, Kumagai K, Motoyoshi N, Kawamoto S, Saiki Y. Predictors of Heparin Resistance Before Cardiovascular Operations in Adults. Ann Thorac Surg 2018; 105:1316-1321. [DOI: 10.1016/j.athoracsur.2018.01.068] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 01/02/2018] [Accepted: 01/22/2018] [Indexed: 10/17/2022]
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20
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Lopez M, Feng C, Vasilyeva O, Eaton MP. Supplemental Antithrombin Is Effective in Achieving Adequate Anticoagulation in Infants and Children With an Inadequate Response to Heparin. J Cardiothorac Vasc Anesth 2017; 31:896-900. [DOI: 10.1053/j.jvca.2016.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Indexed: 01/19/2023]
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21
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Beyer JT, Schoeppler KE, Zanotti G, Weiss GM, Mueller SW, MacLaren R, Fish DN, Kiser TH. Antithrombin Administration During Intravenous Heparin Anticoagulation in the Intensive Care Unit: A Single-Center Matched Retrospective Cohort Study. Clin Appl Thromb Hemost 2016; 24:145-150. [PMID: 27624738 DOI: 10.1177/1076029616668407] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Unfractionated heparin (UFH) is a frequently utilized indirect anticoagulant that induces therapeutic effect by enhancing antithrombin (AT)-mediated procoagulant enzyme inhibition. In suspected heparin resistance (HR) during cardiopulmonary bypass, AT activity may be decreased and AT supplementation helps restore UFH responsiveness. The benefit of AT supplementation in HR over longer durations of UFH therapy is unclear. The objective of this study was to describe and evaluate the use of AT III concentrate in the intensive care units (ICUs) at our institution for improving UFH therapy response over 72 hours. A total of 44 critically ill patients were included in the analysis-22 patients received at least 1 dose of AT and 22 patients received no AT. Thirty (68.2%) of the 44 patients were receiving mechanical circulatory support. Baseline characteristics were similar between groups. The average AT activity prior to AT supplementation was 57.9% in the treatment group, and the median cumulative dose of AT was 786.5 U (9.26 U/kg) per patient. There were no significant differences observed in proportion of time spent in therapeutic range (31.9% vs 35.2%, P = .65), time to therapeutic goal (16.5 vs 15.5 hours, P = .97), or patients who experienced a bleeding event (5 vs 5, P = .99) between groups. In conclusion, AT supplementation had minimal impact on anticoagulant response in this cohort of ICU patients with mild to moderate HR receiving a prolonged UFH infusion. Additional research is needed to define AT activity targets and to standardize AT supplementation practices in patients receiving prolonged heparin infusion.
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Affiliation(s)
- Jacob T Beyer
- 1 Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Kelly E Schoeppler
- 2 Department of Pharmacy, University of Colorado Hospital, Aurora, CO, USA
| | - Giorgio Zanotti
- 3 Department of Surgery, University of Colorado Denver School of Medicine, Aurora, CO, USA
| | - Gregory M Weiss
- 4 Department of Anesthesiology, University of Colorado Denver School of Medicine, Aurora, CO, USA
| | - Scott W Mueller
- 1 Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Robert MacLaren
- 1 Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Douglas N Fish
- 1 Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Tyree H Kiser
- 1 Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
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22
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Chan T, Hwang NC, Lim CH. A statistical analysis of factors predisposing patients to heparin resistance. Perfusion 2016; 21:99-103. [PMID: 16615687 DOI: 10.1191/0267659106pf855oa] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Heparin resistance (HR) is occasionally encountered in cardiac surgery. The objective of this study is to identify possible factors predisposing patients to heparin resistance. Four hundred patients scheduled for elective cardiac surgery requiring the use of cardiopulmonary bypass (CPB) were enrolled in this study. Data collection included: demographic data, types of preoperative anti-coagulant/antiplatelet therapy, preoperative haematological and biochemical laboratory results, medical condition, baseline activated clotting time (ACT) and infusion volume prior to heparinisation. Patients who require 5 mg/kg or more to achieve ACT greater than 400 seconds before CPB were considered to be heparin resistant. All data was tested with a preliminary univariate analysis and factors associated with HR ( p value <0.05) were entered into a multivariate logistic regression analysis. Factors associated with HR with a p value <0.05 are considered predictors for HR. Thirty-two (8.0%) of the 400 patients fulfilled the criteria for HR. Preoperative heparin ( p = 0.025), low molecular weight heparin ( p = 0.049), plateletcount ≥ 300,000/ml ( p = 0.022) and albumin plasma concentration ≤ 35 g/dl 0, = 0.044) are significantly associated with HR. HR patients also tend to require more volume replacement prior to CPB to maintain haemodynamic stability p=0.007).
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Affiliation(s)
- Tanee Chan
- Department of Cardiothoracic Surgery, Perfusion Service, National Heart Centre, Singapore.
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23
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Ranucci M, Ditta A, Boncilli A, Cotza M, Carboni G, Brozzi S, Bonifazi C, Tiezzi A. Determinants of antithrombin consumption in cardiac operations requiring cardiopulmonary bypass. Perfusion 2016; 19:47-52. [PMID: 15072255 DOI: 10.1191/0267659104pf711oa] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Antithrombin (AT) is a natural anticoagulant that is consumed during cardiac operations with cardiopulmonary bypass (CPB). This study is an observational trial aimed at identifying the factors determining the magnitude of the AT consumption during cardiac operations. Two hundred and fifty consecutive adult patients undergoing cardiac operations with CPB were admitted to the study. Preoperative and intraoperative variables were tested with respect to their role in determining AT activity at the end of the operation. At a univariate analysis, eight predictors of AT activity at the end of the operation have been identified: preoperative AT activity; age; diabetes on medication; preoperative haematocrit value; preoperative dialysis; combined operation; CPB duration; lowest temperature on CPB. A multivariate predictive model was created, and five factors remained as independent predictors of AT activity at the end of the operation: preoperative AT activity ( p = 0.001); age ( p = 0.015); combined operation ( p = 0.014); diabetes ( p = 0.013) and CPB duration ( p = 0.001). On this basis, predictive tables of AT consumption have been established for different combinations of risk factors.
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Affiliation(s)
- Marco Ranucci
- Department of Cardiothoracic Anaesthesia, Istituto Policlinico S. Donato, Milan, Italy.
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24
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Levy JH, Sniecinski RM, Welsby IJ, Levi M. Antithrombin: anti-inflammatory properties and clinical applications. Thromb Haemost 2015; 115:712-28. [PMID: 26676884 DOI: 10.1160/th15-08-0687] [Citation(s) in RCA: 117] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 11/08/2015] [Indexed: 12/14/2022]
Abstract
Many humoral and cellular components participate in bidirectional communication between the coagulation and inflammation pathways. Natural anticoagulant proteins, including antithrombin (AT), tissue factor pathway inhibitor, and protein C, suppress proinflammatory mediators. Conversely, inflammation blunts anticoagulant activity and, when uncontrolled, promotes systemic inflammation-induced coagulation, such as those that occur in disseminated intravascular coagulation and severe sepsis. This review discusses the mechanisms of action and clinical use of AT concentrate in critically ill patients and in the settings of perioperative anticoagulation management for surgery and obstetrics. AT is a serine protease inhibitor with broad anticoagulant activity and potent anti-inflammatory properties. In clinical conditions associated with hereditary or acquired AT deficiency, administration of AT concentrate has been shown to restore proper haemostasis and attenuate inflammation. Of note, AT modulates inflammatory responses not only by inhibiting thrombin and other clotting factors that induce cytokine activity and leukocyte-endothelial cell interaction, but also by coagulation-independent effects, including direct interaction with cellular mediators of inflammation. An increasing body of evidence suggests that AT concentrate may be a potential therapeutic agent in certain clinical settings associated with inflammation. In addition to the well-known anticoagulation properties of AT for the treatment of hereditary AT deficiency, AT also possesses noteworthy anti-inflammatory properties that could be valuable in treating acquired AT deficiency, which often result in thrombotic states associated with an inflammatory component.
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Affiliation(s)
- Jerrold H Levy
- Jerrold H. Levy, MD, FAHA, FCCM, DUMC 3094, Durham, NC 27710, USA, Tel.: +1 919 681 6614, Fax: +1 919 681 8994, E-mail:
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25
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Cheng B, Mu JS, Zhang JQ, Bo P. Sudden Thrombosis in Coronary Artery Bypass Grafting Surgery. Chin Med J (Engl) 2015; 128:2835-6. [PMID: 26481760 PMCID: PMC4736880 DOI: 10.4103/0366-6999.167372] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
| | - Jun-Sheng Mu
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing 100029, China
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Chen QQ, Chen WC, Niu J, Shi XW, Chen XH, Hao F. Kaposi's Varicelliform Eruption During Long-term Treatment of Rosacea with 0.03% Tacrolimus Ointment. Chin Med J (Engl) 2015; 128:2833-4. [PMID: 26481759 PMCID: PMC4736885 DOI: 10.4103/0366-6999.167371] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Antithrombin activity and heparin response in neonates and infants undergoing congenital cardiac surgery: a retrospective cohort study. Can J Anaesth 2015; 63:38-45. [DOI: 10.1007/s12630-015-0500-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 08/03/2015] [Accepted: 09/17/2015] [Indexed: 10/23/2022] Open
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Gracheva MA, Urnova ES, Sinauridze EI, Tarandovskiy ID, Orel EB, Poletaev AV, Mendeleeva LP, Ataullakhanov FI, Balandina AN. Thromboelastography, thrombin generation test and thrombodynamics reveal hypercoagulability in patients with multiple myeloma. Leuk Lymphoma 2015; 56:3418-25. [DOI: 10.3109/10428194.2015.1041385] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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McNair E, Marcoux JA, Bally C, Gamble J, Thomson D. Bivalirudin as an adjunctive anticoagulant to heparin in the treatment of heparin resistance during cardiopulmonary bypass-assisted cardiac surgery. Perfusion 2015; 31:189-99. [PMID: 25934498 DOI: 10.1177/0267659115583525] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Heparin resistance (unresponsiveness to heparin) is characterized by the inability to reach acceptable activated clotting time values following a calculated dose of heparin. Up to 20% of the patients undergoing cardiothoracic surgery with cardiopulmonary bypass using unfractionated heparin (UFH) for anticoagulation experience heparin resistance. Although UFH has been the "gold standard" for anticoagulation, it is not without its limitations. It is contraindicated in patients with confirmed heparin-induced thrombocytopenia (HIT) and heparin or protamine allergy. The safety and efficacy of the use of the direct thrombin inhibitor bivalirudin for anticoagulation during cardiac surgery has been reported. However, there have been no reports on the treatment of heparin resistance with bivalirudin during CPB. In this review, we report the favorable outcome of our single-center experience with the alternative use of bivalirudin in the management of anticoagulation of heparin unresponsive patients undergoing coronary artery bypass graft surgery.
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Affiliation(s)
- E McNair
- Department of Pathology and Laboratory Medicine, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada Department of Surgery, Division of Cardiac Surgery, Saskatoon Health Region, Saskatoon, SK, Canada
| | - J-A Marcoux
- Department of Surgery, Division of Cardiac Surgery, Saskatoon Health Region, Saskatoon, SK, Canada
| | - C Bally
- Department of Pathology and Laboratory Medicine, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - J Gamble
- Department of Anesthesiology and Pain Management, College of Medicine and Saskatoon Health Region, Saskatoon, SK, Canada
| | - D Thomson
- Department of Surgery, Division of Cardiac Surgery, Saskatoon Health Region, Saskatoon, SK, Canada
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Sniecinski RM, Levy JH. Anticoagulation management associated with extracorporeal circulation. Best Pract Res Clin Anaesthesiol 2015; 29:189-202. [PMID: 26060030 DOI: 10.1016/j.bpa.2015.03.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 03/20/2015] [Indexed: 11/25/2022]
Abstract
The use of extracorporeal circulation requires anticoagulation to maintain blood fluidity throughout the circuit, and to prevent thrombotic complications. Additionally, adequate suppression of hemostatic activation avoids the unnecessary consumption of coagulation factors caused by the contact of blood with foreign surfaces. Cardiopulmonary bypass represents the greatest challenge in this regard, necessitating profound levels of anticoagulation during its conduct, but also quick, efficient reversal of this state once the surgical procedure is completed. Although extracorporeal circulation has been around for more than half a century, many questions remain regarding how to best achieve anticoagulation for it. Although unfractionated heparin is the predominant agent used for cardiopulmonary bypass, the amount required and how best to monitor its effects are still unresolved. This review discusses the use of heparin, novel anticoagulants, and the monitoring of anticoagulation during the conduct of cardiopulmonary bypass.
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Affiliation(s)
- Roman M Sniecinski
- Emory University School of Medicine, Department of Anesthesiology, 1364 Clifton Rd, NE, Atlanta, GA 30322, USA.
| | - Jerrold H Levy
- Cardiothoracic Anesthesia and Critical Care, Duke University Medical Center, 2301 Erwin Road, 5691H HAFS, Durham, NC 27710, USA.
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Glucocorticoids as modulators of expression and activity of Antithrombin (At): Potential clinical relevance. Thromb Res 2015; 135:183-91. [DOI: 10.1016/j.thromres.2014.10.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Revised: 10/14/2014] [Accepted: 10/29/2014] [Indexed: 12/21/2022]
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Besser MW, Ortmann E, Klein AA. Haemostatic management of cardiac surgical haemorrhage. Anaesthesia 2014; 70 Suppl 1:87-95, e29-31. [DOI: 10.1111/anae.12898] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2014] [Indexed: 11/28/2022]
Affiliation(s)
- M. W. Besser
- Department of Haematology; Papworth Hospital; Cambridge UK
| | - E. Ortmann
- Department of Anaesthesia and Intensive Care; Papworth Hospital; Cambridge UK
- Department of Anaesthesia and Intensive Care; Kerckhoff Klinik Heart and Lung Centre; Bad Nauheim Germany
| | - A. A. Klein
- Department of Anaesthesia and Intensive Care; Papworth Hospital; Cambridge UK
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Krajewski KC, Smith K, Conwall K, Krajewski MP. Achievement of therapeutic anti-Xa levels in a proven heparin-resistant patient through the use of nontraditional high-dose enoxaparin. Ann Pharmacother 2014; 49:130-4. [PMID: 25288822 DOI: 10.1177/1060028014554649] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To describe the successful use of high-dose enoxaparin therapy (1.5 mg/kg subcutaneously twice daily) to attain a therapeutic anti-factor Xa (anti-Xa) level in a cancer patient with heparin resistance. CASE SUMMARY A proven heparin-resistant patient with venous thromboembolism (VTE) and lung cancer who required approximately 66 000 units of unfractionated heparin daily was successfully transitioned to an off-label high-dose enoxaparin (OLHDE) 1.5 mg/kg subcutaneously twice daily. The patient was maintained on this same dose, and therapeutic levels were confirmed via use of the anti-Xa monitoring test. The patient was able to be discharged from the medical floor on this same dose with no further complications of VTE noted. No adverse events from this dosing were observed during the duration of therapy. DISCUSSION Options for overcoming heparin resistance are limited to case reports and small studies. The best course of treatment in the cancer patient is unclear. OLHDE allowed for the transition from intravenous to subcutaneous medication and transition off the medical floor. This case supports the use of OLHDE as a therapeutic option in heparin-resistant patients with cancer. Further study is needed to confirm the efficacy of OLHDE in this patient population. CONCLUSION High-dose enoxaparin may be an option to treat cancer patients with confirmed heparin resistance and venous thromboembolism.
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Affiliation(s)
| | - Kelly Smith
- Veteran's Affairs Western New York Healthcare System, Buffalo, NY, USA
| | - Katherine Conwall
- Veteran's Affairs Western New York Healthcare System, Buffalo, NY, USA
| | - Michael P Krajewski
- State University of New York at Buffalo, School of Pharmacy and Pharmaceutical Sciences"
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Pappalardo F, Agracheva N, Covello RD, Pieri M, De Bonis M, Calabrò MG, Koster A, Zangrillo A. Anticoagulation for Critically Ill Cardiac Surgery Patients: Is Primary Bivalirudin the Next Step? J Cardiothorac Vasc Anesth 2014; 28:1013-17. [DOI: 10.1053/j.jvca.2013.10.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Indexed: 11/11/2022]
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Bagheri K, Honarmand A, Safavi M, Kashefi P, Sayadi L, Mohammadinia L. The evaluations of frequency distribution heparin resistance during coronary artery bypass graft. Adv Biomed Res 2014; 3:53. [PMID: 24627861 PMCID: PMC3950837 DOI: 10.4103/2277-9175.125798] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Accepted: 11/05/2012] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Heparin is one of the most important medication that is used in coronary artery bypass graft (CABG) operations, but some patients demonstrate heparin resistance (HR) during CABG. Heparin resistance was defined as at least one activated clothing time <400 seconds after heparinization and/or the need for purified antithrombin III (AT-III) administration. The goal of this study was the investigation of HR prevalence in our country and relation between HR and post-operative CABG complications. MATERIALS AND METHODS One hundred patients that candidate for CABG were selected and surveyed for HR and complications. The data entered to computer and analyzed by SPSS soft ware. The Chi-square and student t-tests were used for data analysis. RESULTS The prevalence of heparin resistance in our study was 3%. There was no relation among bleeding, cardiac arrest and HR. Bleeding happened in 13 patients of which 1 person was in HR group (33.3%) and 12 in non HR group (12.4%) (P = 0.34). Cardiac arrest happened in 8 patients, 1 person was in HR group (33.3%) and 7 in non HR group (7.2%) (P = 0.22). According our data there were no relation among HR and gender and ventilator dependency time. CONCLUSIONS HR is a nearly prevalent complication among patients that undergone CABG that may led to some complications such as bleeding and cardiac arrest. In our study, we did not find significant relation among them, but in frequency these complications were higher in HR group.
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Affiliation(s)
- Kaivan Bagheri
- Anesthesiology and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Azim Honarmand
- Anesthesiology and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammadreza Safavi
- Anesthesiology and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Parviz Kashefi
- Anesthesiology and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Lale Sayadi
- Anesthesiology and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Leila Mohammadinia
- Anesthesiology and Critical Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
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36
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Tanaka K, Esper S, Bolliger D. Perioperative factor concentrate therapy. Br J Anaesth 2013; 111 Suppl 1:i35-49. [DOI: 10.1093/bja/aet380] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
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Muedra V, Barettino D, D'Ocón P. [Role of antithrombin iii in cardiac surgery]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2013; 60:519-527. [PMID: 23228672 DOI: 10.1016/j.redar.2012.09.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Revised: 09/18/2012] [Accepted: 09/26/2012] [Indexed: 06/01/2023]
Abstract
Coagulation of blood is of multidisciplinary interest. Cardiac surgery produces major changes in the delicate balance between pro-and anti-coagulant serum factors. The role of antithrombin iii has been analysed after finding evidence that associated decreased levels of protein activity to postoperative morbidity and mortality. Supplementing exogenous antithrombin is considered with the aim of optimising outcomes. Its intrinsic anticoagulant and anti-inflammatory properties have stimulated a growing interest, and suggests new lines of research.
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Affiliation(s)
- V Muedra
- Departamento de Anestesiología-Reanimación y Terapéutica del Dolor, Hospital Universitario La Ribera, Alzira, Valencia, España.
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Pieri M, Agracheva N, Di Prima AL, Nisi T, De Bonis M, Isella F, Zangrillo A, Pappalardo F. Primary Anticoagulation With Bivalirudin for Patients With Implantable Ventricular Assist Devices. Artif Organs 2013; 38:342-6. [DOI: 10.1111/aor.12168] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Marina Pieri
- Department of Anesthesia and Intensive Care; San Raffaele Scientific Institute; Milan Italy
| | - Natalia Agracheva
- Department of Anesthesia and Intensive Care; San Raffaele Scientific Institute; Milan Italy
| | - Ambra Licia Di Prima
- Department of Anesthesia and Intensive Care; San Raffaele Scientific Institute; Milan Italy
| | - Teodora Nisi
- Department of Cardiac Surgery; San Raffaele Scientific Institute; Milan Italy
| | - Michele De Bonis
- Department of Cardiac Surgery; San Raffaele Scientific Institute; Milan Italy
| | - Francesca Isella
- Department of Anesthesia and Intensive Care; San Raffaele Scientific Institute; Milan Italy
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care; San Raffaele Scientific Institute; Milan Italy
| | - Federico Pappalardo
- Department of Anesthesia and Intensive Care; San Raffaele Scientific Institute; Milan Italy
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39
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Warkentin TE. Anticoagulant failure in coagulopathic patients: PTT confounding and other pitfalls. Expert Opin Drug Saf 2013; 13:25-43. [DOI: 10.1517/14740338.2013.823946] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Theodore E Warkentin
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton Regional Laboratory Medicine Program, Hamilton General Hospital, Hamilton Health Sciences, 237 Barton St. E, Hamilton, Ontario L8L 2X2, Canada
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40
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Dietrich W, Busley R, Spannagl M, Braun S, Schuster T, Lison S. The Influence of Antithrombin Substitution on Heparin Sensitivity and Activation of Hemostasis During Coronary Artery Bypass Graft Surgery. Anesth Analg 2013; 116:1223-30. [DOI: 10.1213/ane.0b013e31827d0f6b] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Ranucci M, Baryshnikova E, Crapelli GB, Woodward MK, Paez A, Pelissero G. Preoperative antithrombin supplementation in cardiac surgery: A randomized controlled trial. J Thorac Cardiovasc Surg 2013; 145:1393-9. [DOI: 10.1016/j.jtcvs.2012.09.061] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2012] [Revised: 09/06/2012] [Accepted: 09/21/2012] [Indexed: 11/25/2022]
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Badrin O, Kushairi S, Zakaria Z, Sachithanandan A. Successful anticoagulation with fresh frozen plasma for cardiopulmonary bypass in a patient with heparin resistance: a cautionary tale. BMJ Case Rep 2013; 2013:bcr-2013-009112. [PMID: 23632185 DOI: 10.1136/bcr-2013-009112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Heparin resistance (HR) is an increasingly common occurrence due to a greater awareness of the benefits of antithrombosis prophylaxis in hospitalised patients with low molecular weight and unfractionated heparin. Furthermore as more high-risk patients with prior heparin exposure undergo cardiac surgery we can expect to encounter more such cases. Adequate anticoagulation is essential for the safe conduct of any operation requiring cardiopulmonary bypass and is usually achieved with systemic heparinisation. We report a case of successful anticoagulation with the intraoperative administration of fresh frozen plasma in a high-risk coronary patient with HR and highlight the perils of unwitting overheparinisation in such cases. This case highlights the importance of clinical awareness of this phenomenon and the available alternative anticoagulants.
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Affiliation(s)
- Omar Badrin
- Department of Cardiothoracic Surgery, Serdang Hospital, Ministry of Health, Kuala Lumpur, Malaysia
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43
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Finley A, Greenberg C. Review article: heparin sensitivity and resistance: management during cardiopulmonary bypass. Anesth Analg 2013; 116:1210-22. [PMID: 23408671 DOI: 10.1213/ane.0b013e31827e4e62] [Citation(s) in RCA: 131] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Heparin resistance during cardiac surgery is defined as the inability of an adequate heparin dose to increase the activated clotting time (ACT) to the desired level. Failure to attain the target ACT raises concerns that the patient is not fully anticoagulated and initiating cardiopulmonary bypass may result in excessive activation of the hemostatic system. Although antithrombin deficiency has generally been thought to be the primary mechanism of heparin resistance, the reasons for heparin resistance are both complex and multifactorial. Furthermore, the ACT is not specific to heparin's anticoagulant effect and is affected by multiple variables that are commonly present during cardiac surgery. Due to these many variables, it remains unclear whether decreased heparin responsiveness as measured by the ACT represents inadequate anticoagulation. Nevertheless, many clinicians choose a target ACT to assess anticoagulation, and interventions aimed at achieving the target ACT are routinely performed in the setting of heparin resistance. Treatments for heparin resistance/alterations in heparin responsiveness include additional heparin or antithrombin supplementation. In this review, we discuss the variability of heparin potency, heparin responsiveness as measured by the ACT, and the current management of heparin resistance.
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Affiliation(s)
- Alan Finley
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, 25 Courtenay Drive, Charleston, SC 29425, USA.
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Isil CT, Yazici P, Topuz U, Erek E, Bakir I. Management of heparin resistance in an emergency cardiac surgical patient. Indian J Anaesth 2012; 56:430-1. [PMID: 23087482 PMCID: PMC3469938 DOI: 10.4103/0019-5049.100849] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Canan Tulay Isil
- Department of Anesthesiology, Istanbul Mehmet Akif Ersoy, Thoracic and Cardiovascular Surgery, Training and Research Hospital, Istanbul, Turkey
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45
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Bosch YP, Weerwind PW, Nelemans PJ, Maessen JG, Mochtar B. An Evaluation of Factors Affecting Activated Coagulation Time. J Cardiothorac Vasc Anesth 2012; 26:563-8. [DOI: 10.1053/j.jvca.2012.03.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Indexed: 11/11/2022]
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Ranucci M, Ballotta A, Kandil H, Isgrò G, Carlucci C, Baryshnikova E, Pistuddi V. Bivalirudin-based versus conventional heparin anticoagulation for postcardiotomy extracorporeal membrane oxygenation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:R275. [PMID: 22099212 PMCID: PMC3388709 DOI: 10.1186/cc10556] [Citation(s) in RCA: 166] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/06/2011] [Revised: 10/08/2011] [Accepted: 11/20/2011] [Indexed: 12/20/2022]
Abstract
Introduction Extracorporeal membrane oxygenation (ECMO) after cardiac operations (postcardiotomy) is commonly used for the treatment of acute heart failure refractory to drug treatment. Bleeding and thromboembolic events are the most common complications of postcardiotomy ECMO. The present study is a retrospective comparison of the conventional heparin-based anticoagulation protocol with a bivalirudin-based, heparin-free protocol. Endpoints of this study are blood loss, allogeneic blood product use, and costs during the ECMO procedure. Methods A retrospective study was undertaken in the setting of cardiac surgery, anesthesia, and intensive care departments of a university research hospital. Twenty-one patients (12 adults and nine children) who underwent postcardiotomy ECMO from 2008 through 2011 were retrospectively analyzed. The first consecutive eight patients were treated with heparin-based anticoagulation (H-group) and the next 13 consecutive patients with bivalirudin-based anticoagulation (B-group). The following parameters were analyzed: standard coagulation profile, thromboelastographic parameters, blood loss, allogeneic blood products use, thromboembolic complications, and costs during the ECMO treatment. Results Patients in the B-group had significantly longer activated clotting times, activated partial thromboplastin times, and reaction times at thromboelastography. The platelet count and antithrombin activity were not significantly different, but in the H-group a significantly higher amount of platelet concentrates, fresh frozen plasma, and purified antithrombin were administered. Blood loss was significantly lower in the B-group, and the daily cost of ECMO was significantly lower in pediatric patients treated with bivalirudin. Thromboembolic complications did not differ between groups. Conclusions Bivalirudin as the sole anticoagulant can be safely used for postcardiotomy ECMO, with a better coagulation profile, less bleeding, and allogeneic transfusions. No safety issues were raised by this study, and costs are reduced in bivalirudin-treated patients.
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Affiliation(s)
- Marco Ranucci
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, Via Morandi 30, 20097 San Donato Milanese (Milan), Italy.
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Muedra V, Bonanad S, Gómez M, Villalonga V, Sánchez F, Llopis JE. Relationships between antithrombin activity, anticoagulant efficacy of heparin therapy and perioperative variables in patients undergoing cardiac surgery requiring cardiopulmonary bypass. Perfusion 2011; 26:487-95. [PMID: 21665912 DOI: 10.1177/0267659111412999] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION A study on 149 cardiopulmonary bypass (CPB) patients was performed to elucidate possible relationships between antithrombin (AT) activity and a subject's clinical profile or surgery characteristics. METHODS An initial dose (300 IU/kg) of heparin was administered before CPB. Additional boluses (100 IU/kg) were administered if the activated clotting time (ACT)≤460 s. AT activity and hematological parameters were determined preoperatively, during and after CPB, and at 12, 24, 36, and 48 hours post-intervention. RESULTS 29.5% patients required an additional dose of heparin during CPB. Preoperative AT was 96.5 ± 13.9% in all but 4 patients. AT was significantly lower during CPB and upon leaving the operating room (59.7%-80.0%). A small, but significant, inverse correlation was observed between AT at the end of CPB and the patient's age, as well as between basal preoperative AT and total heparin administered. CONCLUSIONS Patient's age could be a moderate indicator of AT activity drop and low preoperative AT activity could be a sign of reduced anticoagulant efficacy of heparin during CPB.
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Affiliation(s)
- V Muedra
- Department of Anesthesia, Critical Care and Pain Therapy, La Ribera University Hospital, Alzira, Valencia, Spain.
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48
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Abstract
Despite the development of newer anticoagulants, unfractionated heparin remains an indispensible agent in the treatment of thrombotic disorders. Heparin exerts its major effect via antithrombin, converting antithrombin to a more efficient inhibitor of circulating thrombin (factor IIa), factor Xa, factor IXa, factor XIIa, and kallikrein. However, due to the multiple anticoagulant mechanisms of heparin, differential molecular weight-based clearance, issues of heparin resistance, and patient-specific characteristics (age, weight, gender, and tobacco), attaining therapeutic anticoagulation is complicated. As a result, a minority of patients in major clinical trials achieve an activated partial thromboplastin time within the target window in an appropriate time-frame despite the use of weight-based titration nomograms. The resultant under- or over-therapeutic anticoagulation is associated with increased risks of ischemic and bleeding complications, suggesting the importance of maintaining heparin anticoagulation within a relatively narrow therapeutic range. In this review we discuss the mechanisms of heparin action, clinical ramifications of incorrect dosing in major trials, and attempts to improve the achievement of therapeutic anticoagulation.
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Heparin dose response is independent of preoperative antithrombin activity in patients undergoing coronary artery bypass graft surgery using low heparin concentrations. Anesth Analg 2010; 111:856-61. [PMID: 20142342 DOI: 10.1213/ane.0b013e3181ce1ffa] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Unfractionated heparin's primary mechanism of action is to enhance the enzymatic activity of antithrombin (AT). We hypothesized that there would be a direct association between preoperative AT activity and both heparin dose response (HDR) and heparin sensitivity index (HSI) in patients undergoing coronary artery bypass graft surgery. METHODS Demographic and perioperative data were collected from 304 patients undergoing primary coronary artery bypass graft surgery. AT activity was measured after induction of general anesthesia using a colorimetric method (Siemens Healthcare Diagnostics, Tarrytown, NY). Activated coagulation time (ACT), HDR, and HSI were measured using the Hepcon HMS Plus system (Medtronic, Minneapolis, MN). Heparin dose was calculated for a target ACT using measured HDR by the same system. Multivariate linear regression was performed to identify independent predictors of HDR. Subgroup analysis of patients with low AT activity (<80% normal; <0.813 U/mL) who may be at risk for heparin resistance was also performed. RESULTS Mean baseline ACT was 135 ± 18 seconds. Mean calculated HDR was 98 ± 21 s/U/mL. Mean baseline AT activity was 0.93 ± 0.13 U/mL. Baseline AT activity was not significantly associated with baseline or postheparin ACT, HDR, or HSI. Addition of AT activity to multivariable linear regression models of both HDR and HSI did not significantly improve model performance. Subgroup analysis of 49 patients with baseline AT <80% of normal levels did not reveal a relationship between low AT activity and HDR or HSI. Preoperative AT activity, HDR, and HSI were not associated with cardiac troponin I levels on the first postoperative day, intensive care unit duration, or hospital length of stay. CONCLUSION Although enhancing AT activity is the primary mechanism by which heparin facilitates cardiopulmonary bypass anticoagulation, low preoperative AT activity is not associated with impaired response to heparin or to clinical outcomes when using target ACTs of 300 to 350 seconds.
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Jung HJ, Kim JB, Im KS, Oh SH, Lee JM. Heparin resistance during cardiopulmonary bypass. J Cardiovasc Med (Hagerstown) 2009; 10:940-1. [DOI: 10.2459/jcm.0b013e32832ffca0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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